Just Push It Down? Esophageal Bougienage for Coins

Written by Vivian Lei

Spoon Feed
Esophageal bougienage is an underutilized bedside technique for managing retained esophageal coins.

Why does this matter?
Despite evidence that esophageal bougienage is safe, effective, and cost efficient compared to endoscopy, it remains underutilized in the ED for management of esophageal coins.

Time to bougie down the esophagus
At the authors’ study site, a quaternary care pediatric emergency department, pediatric EM physicians have been performing esophageal bougienage since 2004. The procedure is performed using a Hurst Dilator to push the foreign body into the stomach. Sedation is not required. Candidates for the procedure are required to meet all the following criteria:

  • Single coin ingested and confirmed to be in the esophagus
  • No respiratory distress
  • No prior esophageal foreign body, gastroesophageal surgery or esophageal disease
  • Witnessed ingestion <24 hours prior to presentation

In their retrospective analysis of pediatric patients presenting to the ED with an esophageal coin, 205 patients were identified, with a median age of 3.7 years. Bougienage was attempted in 147 patients with a success rate of 97%. Endoscopy was attempted in 56 patients, with 100% success. Bougienage was not associated with any major complications, and minor complications were few: emesis (6), gagging (1), and oral abrasion (1). Endoscopy was associated with 1 major complication in a 21-month-old requiring reintubation after the procedure. Median hospital length-of-stay for bougienage was 2.18 hours vs 11.92 hours for endoscopic retrieval. Mean hospital charges for successful bougienage were also significantly lower, with a median of $3,533 vs $12,679 for endoscopic retrieval.

Unfortunately, in a nationwide electronic survey of ED physicians, over one third of respondents reported they had never heard of esophageal bougienage. Only 6.6% of respondents reported their site used the technique. The largest reported barriers to use were lack of provider training and perceived risk of complications. The current data seem to refute these concerns, making further education and prospective studies on this technique necessary.

Another Spoonful
Hennepin County has a nice video about esophageal bougienage.

Source
Esophageal Bougienage for Management of Lodged Esophageal Coins: Safe, Effective, Efficient, and Underused. Pediatr Emerg Care. 2022 Sep 30. doi: 10.1097/PEC.0000000000002849. Online ahead of print.

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